Similar presentations

2 Learning Objectives Describe characteristics of high-alert medicationsDescribe characteristics of effective risk-reduction strategies for high-alert medicationsReview the medication use process and identify possible sites for errorOutline the steps to developing a comprehensive risk-reduction programPresent and discuss examples of the implementation of risk-reduction programs

3 High-Alert Medication: Definition1A high-alert medication is a medication that:has a high risk of causing patient harm when used in error.A high-alert medication is not necessarily a medication that has a higher risk of being used in error.Sakowski et. Al. evaluated perceived severity of medication errors saw high-alert medications as 5% more likely to have a moderate or severe adverse reaction21-2 – PMID

5 High-Alert MedicationsJoint Commission standard MMInstitutions must:Have a list of high-alert medicationsDevelop a process for mitigating risk with high-alert medicationsImplement their process for managing high-alert medicationsAny list and any process meet minimum requirements65 -6 -However, to actually improve patient safety, it is necessary to carefully design an individualized high-alert medication, and now we will take a look at a few factors to consider when developing a high-alert medication list.

6 Developing a High-Alert Medication ListISMP’s lists a good starting point3,4Add or subtract drugs based on institutional needsDrugs new to formularyAppropriate criteria for therapy not establishedStaff less familiar with processes to manage adverse effects.Drugs locally identified to have caused patient harmDrugs of particular risk to an institution’s patient population

8 Developing a High-Alert Medication ListList should be dynamic6List should be known to all practitionersList should be backed by processes that reduce errors, and which reduce the risk associated with errorsDynamic – Update the list. Add and subtract medications as patterns in use change. Having a high-alert list that has not been updated since its inception is suboptimal.

9 Low-Leverage Risk Reduction StrategiesStaff Education ProgramsLabels & Manual Double ChecksBulletinsGiven these examples of strategies considered low-leverage, let’s discuss a few of the characteristics of these processes that limit their overall effectiveness.

10 Low-Leverage Risk Reduction StrategiesPassiveInform agents that may prevent medication errors, but do not prevent errors themselvesIntermittentMay influence behaviors in short term9, with returns dissipating over timeFocus on IndividualsUtility limited by fatigue, time constraints, may create sense of punitive cultureDo improve awareness, but must be combined with a more comprehensive program to maximize effectiveness9 – PMIDA more comprehensive program will have to include high-leverage strategies. I have included a list of strategies from ISMP in your handout packet, and will outline a few strategies on the next slide

12 High-Leverage Risk Reduction StrategiesActiveStrategies themselves play a role in making errors less likelyContinuousLess subject to waxing and waning effectivenessFocus on SystemsIndefatigable, high yield, pulls blame from individualsMore effective, but demand more resourcesSelect strategies relevant to likely errorsExamples of High-Leverage Risk Reduction strategies outlined in handoutIn order to implement effective and efficient strategies, programs must be designed to target likely errors. Next, I would like to review the medication use process and sites where errors may occur

13 Medication Use Process: OverviewPrescribing-Selection of agent-Selection of doseTranscribing-Recording prescription in writing-Transferring records between systemsMonitoring-Signs of efficacy-Signs of adverse reactions-Reporting of resultsDispensing/Storage-Preparation of product-Delivery to storageAdministration-Retrieval of product-Administration to patient

17 Other Considerations for Error ReductionWant to utilize multiple risk-reduction strategies that target multiple pathwaysReducing medication errors is a multidisciplinary responsibilityReporting errors is critical for identifying areas for improvementTargeting multiple steps is key to success – an error that slips through one pathway is unlikely to be recognized downstream, and an error downstream in the pathway will nullify the most finely tuned upstream processes

18 Examples of Medication ErrorsError: Patient prescribed IV acyclovir for possible meningitis and dosed on actual body weight rather than adjusted body weight resulted in dose 20% higher than recommended.Possible negative impact of error: Expose patient to higher risk of adverse effects.Possible strategy to reduce error: CPOE that automatically calculates dose based on patient’s height and weight.Error: Patient prescribed IV acyclovir for possible meningitis and dosed on actual body weight rather than adjusted body weight resulted in dose 20% higher than recommended.Possible negative impact of error: Expose patient to higher risk of adverse effects.Possible strategy to reduce error: CPOE that automatically calculates dose based on patient’s height and weight.Encourage audience to start thinking about medication errors they have seen in their practice and what sort of risk-reduction strategy could be used to prevent such an error in the future, or how an implemented strategy helped identify or manage the error

19 Examples of Medication ErrorsError: Patient prescribed Medrol dose pack. Prescriber labeled “use as directed on package”. Dispensed with label “take two today, and then one daily until gone”.How error was detected: Detected during data entry double-check.How error was mitigated: Called the patient and told her to follow the instructions in the package, not the label we affixed to the product.

20 Examples of Medication ErrorsError: Multiple instances of wrong drug product being selected for fill at a community pharmacy.How error was detected: Barcode NDC verification comparing bottle to product specified at data entry.How error was mitigated: Put the wrong bottle back on the shelf and selected the correct one.Open floor to other medication error reports

21 Putting it All TogetherNow that we’ve detailed the principles involved in selecting medications for a high-alert medication list and what strategies are likely to be effective at reducing risk associated with medications, I want to go through an example of how one might develop a comprehensive program to reduce risk associated with high-alert medicationsDeveloping a comprehensive risk-reduction program for high-alert medications

23 A Comprehensive Institutional Program: InsulinStep 1: Build a list of high-alert medicationsWhy insulin10?Significant risk of hypoglycemiaunconsciousness, possibly comaRemember that the risk of patient harm is the primary factor in determining what medications are included in a high-alert medication list10 – micromedex insulin

28 A Comprehensive Community Program: WarfarinStep 1: Build a list of high-alert medicationsWhy warfarin12?Narrow therapeutic indexSignificant risks associated with both supratherapeutic (bleeding) and subtherapeutic (DVT, PE, stroke) dosagesRemember that the risk of patient harm is the primary factor in determining what medications are included in a high-alert medication list12 – micromedex warfarin

33 SummaryHigh-alert medications have increased risk of causing patient harm when used in errorCombining multiple low and high-leverage risk-reduction strategies are essential to improving outcomesRisk-reduction strategies need to be selected based on errors likely to occur with a particular drugMonitoring programs for effectiveness is essential to guaranteeing sustained success